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■ rr Waste Tir -SU * y & ins•pection Repo nspection Report Number ■ <br /> "Eim State of California <br /> CIWMB 181 e ) <br /> Califofornia Integrated WasttManagement <br /> Survey Porm - Page 1 1 8 . 1 0 2 .56 e Management Board - 0 8. <br /> ' <br /> Part A- Surve BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection <br /> � �171 <br /> c � - � , Inspection Type (Fill one) <br /> Site Suffix: ( IP Routine Q Re-inspection 0 Referral Q Observation <br /> Local r�- If Referral,choose referral type(Fill one) <br /> Identifier: ��;, ,.- r Q CHP O CIWMB tQ Complaint Q Educational Visit Q Other <br /> Business or Facility Name — �-— <br /> Inspected By Inspector <br /> Physical AddressC r <br /> - <br /> /Z I (IJ <br /> Street <br /> �D•±iG_ v,� � 52 <br /> U Inspection Date <br /> City State ZIP Code Time In Time Out <br /> 0 AM <br /> Business Rep Title Q AM <br /> m0 PM m m 0 P <br /> WG rte C7,r ns;.+,,. <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) �f 7 (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> a'Lam' 0 Active 0 Passenger (R) Generator D Outdoor <br /> O Q Closed 0 Altered <br /> GPS Latitude Q Hauler 0 Indoor <br /> O Q Inactive (E)Truck <br /> Longitude - O Planned 0 OTR End Use Container �I <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair Q Trucking Fleet .Q Government Q Retreader o Dismantler gTire Derived Fuel <br /> Q Used Tire Dealer Q Auto Body Q Car Dealer Q Collection O Crumb Rubber - <br /> Q Service Station Q Hauler O Agriculture Q Shredder ® Other I r/�r.r•�_ �L -� <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> Q Notice Of Violation Q Extension <br /> O O 'PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> O O i PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> O O PRC§42956-Registration/Decal in Vehicle <br /> O O 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date <br /> OO 14 CCR§18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB <br /> �•�� I <br /> Q Q 14 CCR§18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days (Required for NOV or E)M <br /> O O 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> O Q 14 CCR§18460.2- -Manifest System Requirements for Registered Waste Tire Haulers Q Referred 1 CIWMB Enforcement <br /> O Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities �. <br /> O Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators 0 In Compliance - No Violations <br /> Q Q Other: § <br /> Comments r L Z K <br /> 0 <br /> ��✓'—L�4d•.�� �,�XS�r- -�+/Y:, �'i -,1 (..�t�.�� .(.fir.. „ <br />} <br /> riLa, <br /> - f <br /> Inspection Form Included: 0 - <br /> Comments Included: 0 <br /> Business Rep's Signature Phone Number Inspectors Signature Phone Number <br /> X ,�, i p 62081 <br /> INSTRUCTIONS ON BACK Correct:� Incorrect: )� � �J .�Its !� ,� � 1 <br /> ■ y. ® ■ <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />